G-237 (Proposed) Statement Regarding Marital Status

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

RRB Claim No.:

Statement Regarding
Marital Status

Employee's SS No.:
Employee's Name:

Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect the
information on this form under Section 7(b)(6) of the
Railroad Retirement Act of 1974. The information will be
used to determine entitlement to benefits under this Act.
You are not required to provide this information. However,
your failure to do so may result in loss of benefits for the
applicant. Your cooperation in furnishing the information
is, therefore, very much appreciated.
We estimate this form takes an average of 15 to 20
minutes per response to complete, including the time for

reviewing the instructions, getting the needed data and
reviewing the completed form. Federal agencies may not
conduct or sponsor, and respondents are not required to
respond to a collection of information unless it displays a
valid OMB number. If you wish, send comments regarding
the accuracy of our estimate or any other aspect of this
form, including suggestions for reducing completion time, to
Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, Illinois
60611-1275.

INSTRUCTIONS: Unless you are told to skip and go to another item, all questions must be answered or marked “Unknown.”
Type or print legibly in ink. If you need more space than is provided to answer a question, use Item 15, Remarks, for this purpose.

1 Your Full Name

Name at Birth (If Different)

2 Name of Marriage Partner
3 Did you ever live with anyone else as husband and wife?

R Yes
R No

a Name of Person
Date Relationship Started

How Relationship Ended

Date and Place Relationship Ended

Kind of Relationship (Ceremonial, etc.)

How Relationship Ended

Date and Place Relationship Ended

4 Did the person you were living with ever live with anyone else as husband
and wife?

a Name of Person
Date Relationship Started

R Yes
R No

Go to Item 4a
Go to Item 5

Kind of Relationship (Ceremonial, etc.)

How Relationship Ended

Date and Place Relationship Ended

b Name of Person
Date Relationship Started

Go to Item 4

Kind of Relationship (Ceremonial, etc.)

b Name of Person
Date Relationship Started

Go to Item 3a

Kind of Relationship (Ceremonial, etc.)

How Relationship Ended

Date and Place Relationship Ended

5 Enter when and why you and the marriage partner separated.

Continued

Month

Year

Form G-237 (xx-xx) Destroy prior editions

6 a Did the marriage partner ever attempt to end your marriage by divorce
or annulment proceedings?

b Were you served with a notice of such proceedings?

R Yes
R No

Go to Item 6b

R Yes
R No

Go to Item 6c

Go to Item 7

Go to Item 6d

c Enter the City and State where the notice was served.

Go to Item 7
Month

d Enter when and how you learned of the attempt to end your marriage.

Year

7 Enter why you know or believe that your marriage to the marriage partner was or was not terminated by divorce or annulment.

8 a To your knowledge, is the marriage partner deceased?

R Yes
R No

Go to Item 8b
Go to Item 9

b Enter the marriage partner’s date and place of death.
Month

Year

State

City

9 a Do you know where the marriage partner can be located?

R Yes
R No

Go to Item 10

Go to Item 9b
Go to Item 9c

b Enter the marriage partner’s address below.
Street

City

State

c Do you know of any person(s) who knows where the marriage partner

R Yes
R No

can be located?

Go to Item 10

Go to Item 9d
Go to Item 10

d Enter the name and address of such person(s).
Name

Address

Name

Address

10 Enter the following information about the marriage partner's closest blood relatives.
Name

Relationship

Address

11 Where and when did you live after your separation from the marriage partner?
City or Town

Form G-237 (xx-xx)

County

Page 2

State

To

From
Month

Year

Month

Year

12 a Do you know of anyone who can furnish a statement about the places

R Yes
R No

where you lived after your separation from the marriage partner?

b Will you have such person(s) complete Form G-238, Statement of

Go to Item 12b
Go to Item 13a

R Yes
R No

Residence, and forward it to the Railroad Retirement Board?

13 Do you know where the marriage partner lived after your separation?

R Yes
R No

Go to Note and Item 14a
Go to Item 14a

Note: Complete Form G-238, Statement of Residence, and forward it to the Railroad Retirement Board.

14 a Do you know of anyone (relatives or friends) who can furnish a state-

R Yes
R No

ment about where the marriage partner lived after your separation?

b Will you have such person(s) complete Form G-238, Statement of

Go to Item 14b
Go to Item 15

R Yes
R No

Residence, and forward it to the Railroad Retirement Board?

15 Remarks: Use this space for the continuation of answers to other items. Be sure to include the item number at the beginning
of the answer you wish to continue. You may also use this space to enter any additional information that you feel may be
important to include. If you need more space, use the back of this page.

16 Certification: Failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil penalties, or
both. I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for withholding
information to cause or prevent payment of benefits by the RRB. I affirm that to the best of my knowledge, the information I have
given is true, complete, and correct.
Date (Month, Day, Year)

Signature of person making statement
Signature (First Name, Middle Initial, Last Name)

Daytime Telephone Number

(

)

Mailing Address (Number and Street, Apt. No., P.O. Box, etc.)

City and State

ZIP Code

County (if any)

17 If the certification is signed by mark (X) in Item 16, two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.

a. Signature of Witness

b. Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Address (Number and Street, City, State and ZIP Code)

Daytime Telephone Number

Daytime Telephone Number

(

(

)
Page 3

)
Form G-237 (xx-xx)